Monday, June 23, 2008

CMS Attempting To Put Out A Forest Fire With a Water Pistol?

The well-intentioned CMS EHR Demonstration Project will introduce EHR's to perhaps a few hundred primary care practices over the next few years.

CMS is developing a new demonstration initiative that aims to reward delivery of high-quality care supported by the adoption and use of electronic health records in physician practices. This initiative expands upon the foundation created by the Medicare Care Management Performance (MCMP) Demonstration. The goal of this 5-year demonstration is to foster the implementation and adoption of EHRs and health information technology (HIT) more broadly as effective vehicles not only to improve the quality of care provided, but also to transform the way medicine is practiced and delivered ...

On June 10, 2008 CMS announced the selection of 12 community partners to help CMS implement this demonstration. The approved community partners in each site represent diverse collaborations of organizations including, but not limited to, varied HIT stakeholder collaborations, medical societies, primary care professional organizations and health departments. Recruitment of physician practices in the first four Phase I sites will begin in the fall of 2008. Recruitment for Phase II sites will begin in the fall of 2009.

I believe, however, that the CMS demonstration project is unlikely to cause the "tipping point" in EHR diffusion to be reached.

In the NEJM's June 2008 article "
Electronic Health Records in Ambulatory Care — A National Survey of Physicians " the following figures were cited:

Just 4 percent of doctors use software that includes electronic prescriptions and drug-interaction warnings. A larger group, 13 percent, opted for more basic software that only allowed them to enter notes and medical histories. Those who use the computer systems said they helped improve patient care.

After 30+ years of effort, that's simply amazing. The causes of the low diffusion go very far beyond the article summary's conclusion that
... Financial barriers were viewed as having the greatest effect on decisions about the adoption of electronic health records.

Of course, as readers here know, I have different views about the barriers. And, the barriers are not mysterious forces, just forces whose acknowledgement seems to encounter much resistance as they are "politically incorrect" (health IT is a silver bullet to solve healthcare's ills, after all) and potentially damaging to the profits of the "HIT-industrial complex."

Until (as one commenter to my writings said) the "skeletons in the closet of the HIT ecosystem" - that is, the sociotechnical issues - are acknowledged and dealt with, I believe HIT will continue with suboptimal diffusion rates.

I also consider the "HIT ecosystem" itself unhealthy, consisting of:

  • the optimists or idealists (who believe HIT will "revolutionize" medicine without seeming to care much about potential political or societal downsides or potential unwelcome effects on the medical professions and their practitioners, and relentlessly promote only HIT virtues, real and imagined -- "Pollyannas cheerleading for health care information technology", as put by one of my colleagues),
  • the opportunists (who come in two flavors - the industrialists, who will leverage the enthusiasm generated by the optimists to make money, e.g., payers, vendors, without caring about other issues; and the ideologues, who will use the enthusiasm to advance their ideological goals such as increasing control over clinicians and/or ushering in nationalized healthcare - think Hillary);
  • the technicians - the IT people who design and implement HIT, who probably act as a negative feedback or inhibitory force through not understanding medical culture and the "hiding in plain sight" complexities of healthcare and HIT; and
  • the realists (a minority) who see HIT as a facilitative tool to clinicians if done right, done well, with consideration to downsides and unexpected consequences, and not overdone and oversold.

Many in Medical Informatics fit into the latter category.

-- SS

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